Provider Demographics
NPI:1386755114
Name:BULLOCK, REX (DDS)
Entity type:Individual
Prefix:DR
First Name:REX
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 WASHBURN AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-4362
Mailing Address - Country:US
Mailing Address - Phone:951-737-1149
Mailing Address - Fax:
Practice Address - Street 1:914 WASHBURN AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-4362
Practice Address - Country:US
Practice Address - Phone:951-737-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA253701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice